Company Overview:
Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.
Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.
Job Summary and Responsibilities:

JOB SUMMARY:

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  Responsible for analyzing healthcare data to identify business opportunities, strengthen program integrity, and support client needs in both financial and outcomes-related areas. This role serves as a client-facing resource for delivering actionable insights and reporting while also contributing to federal and state program requirements such as Higher-Weighted Diagnosis Related Group (HWDRG) reviews and Improper Payment Reduction Strategies (IPRS). The position combines technical analytics, claims review, quality assurance, and provider education to ensure accurate data use, compliance, and improved healthcare outcomes.

Client & Reporting Responsibilities

• Understand client contract requirements, including deliverables related to HWDRG reviews, improper payment analysis, and reporting timelines.
• Deliver and present reports with appropriate QA, analysis, and commentary.
• Monitor the production and distribution of automated reports and manage the report delivery calendar.
• Gather reporting requirements, assign priorities, and package requests for the technical team.

• Manage and fulfill requests for ad hoc reporting, balancing timeliness with production priorities.

Data Analytics & Technical Skills

• Maintain working knowledge of the database environment, including key tables and joins, and how workflow processing relates to database transactions.
• Perform quality checks of analytics queries, reports, and applications, identifying disparities and actionable resolutions.
• Conduct analyses of Medicare claims and other data sources (e.g., CERT, PEPPER, Comparative Billing Reports) to identify improper payment risks, coding anomalies, and utilization patterns.

• Support development and implementation of an IPRS by identifying vulnerabilities, prioritizing provider/service areas, and contributing to measurable improvement goals.

Program Integrity & HWDRG Responsibilities

• Review HWDRG claims to ensure diagnostic, procedural, and discharge information align with medical records and physician documentation.
• Contribute to utilization review and DRG validation processes, ensuring compliance with CMS guidelines.
• Support sampling methodology to ensure findings are statistically valid and representative of claim populations.
• Refer claims for physician review where medical judgment is required.

• Identify potential Quality of Care concerns and refer for appropriate review.

Provider Education & Outreach

• Assist in developing provider education strategies, including one-on-one education, feedback tools, and data-driven insights to reduce improper coding and improve compliance.
• Support dissemination of best practices across providers and stakeholders, while minimizing provider burden.
• Participate in provider education sessions with clinical and coding subject matter experts.

Qualifications:

Skills

• Demonstrated understanding of principles, practices, and techniques of application development, including programming and scripting.
• Proficiency in Microsoft Excel, Microsoft Access, and VB programming/scripting within Excel and Access.
• Preferred skills in SAS, SQL, and statistical analysis.
• Strong data analytics capability with ability to generate graphs, dashboards, and written reports.
• Knowledge of Medicare claims data, DRG validation, and improper payment methodologies is not required although it is desired.
• Strong communication skills for both client-facing and internal collaboration, including the ability to explain technical findings in clear, actionable language.

Education

• Bachelor’s degree required; Master’s degree preferred in Computer Science, Statistics, Mathematics, Epidemiology, Health Services Research, or equivalent professional experience.

Client & Reporting Responsibilities

• Understand client contract requirements, including deliverables related to HWDRG reviews, improper payment analysis, and reporting timelines.
• Deliver and present reports with appropriate QA, analysis, and commentary.
• Monitor the production and distribution of automated reports and manage the report delivery calendar.
• Gather reporting requirements, assign priorities, and package requests for the technical team.
• Manage and fulfill requests for ad hoc reporting, balancing timeliness with production priorities

Program Integrity & HWDRG Responsibilities

• Review HWDRG claims to ensure diagnostic, procedural, and discharge information align with medical records and physician documentation.
• Contribute to utilization review and DRG validation processes, ensuring compliance with CMS guidelines.
• Support sampling methodology to ensure findings are statistically valid and representative of claim populations.
• Refer claims for physician review where medical judgment is required.
• Identify potential Quality of Care concerns and refer for appropriate review